WHO: Treatment adherence = the extent to which a person's behaviour corresponds with the agreed recommendations from a healthcare provider

5 dimensions:

• Health system: patient-provider relationship, poorly developed health services with inadequate or non-existent reimbursement by health insurance plans, poor medication distribution systems, lack of knowledge and training for health care providers on managing chronic diseases, overworked health care providers, lack of incentives and feedback on performance, short consultations, weak capacity of the system to educate patients and provide follow-up, inability to establish community support and self-management capacity.
• Socio/economic: Low SES, poverty, illiteracy, low level of education, unemployment, lack of effective social support networks, unstable living conditions, long distance from treatment centre, high cost of transport, high cost of medication, changing environmental situations, culture and lay beliefs about illness and treatment, and family dysfunction.
• Therapy related: Severity of symptoms, level of disability (physical, psychological, social and vocational), rate of progression and severity of the disease, and the availability of effective treatments. Affect pt risk perception, importance of adherence.
• Patient related: forgetfulness; psychosocial stress; anxieties about possible adverse effects; low motivation; inadequate knowledge and skill in managing the disease symptoms and treatment; lack of self-perceived need for treatment; lack of perceived effect of treatment; negative beliefs regarding the efficacy of the treatment; misunderstanding and non-acceptance of the disease; disbelief in the diagnosis; lack of perception of the health risk related to the disease; misunderstanding of treatment instructions; lack of acceptance of monitoring; low treatment expectations; low attendance at follow-up; hopelessness and negative feelings; frustration with health care providers; fear of dependence; anxiety over the complexity of the drug regimen, and feeling stigmatized by the disease. Perceived cost:benfit
• Condition related: complexity of the medical regimen, duration of treatment, previous treatment failures, frequent changes in treatment, the immediacy of beneficial effects, side-effects, and the availability of medical support to deal with them.

Solutions

• Health system: training for adherence management, motivational interview, continuous treatment monitoring/reassessment, health system design to support adherence management, good rapport, home medication review.
• Socioeconomic: Universal and sustainable financing, affordable prices and reliable supply systems, Community-based organizations, education of illiterate patients, assessment of social needs, Social support (i.e. informal or formal support received by patients from other members of their community), closing the gap scheme (access meds)
• Therapy related: reduce dose frequency and the incidence of side-effects. Combination pills to reduce pill burden. Justify each medication.
• Condition related: Identify and treat disease specific symptoms, treat comorbidities affecting adherence (anxiety, depression), adherence counselling with screen for depression
• Patient related: Patients need to be informed, motivated and skilled in the use of cognitive and behavioural self-regulation strategies. Patient motivation is a key area which is difficult. Memory aids. Webster packs.